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PHRM 865: Theraputics V > Lecture 27: Opportunistic Infections > Flashcards

Lecture 27: Opportunistic Infections Flashcards

1
Q

What is the main cause for Opportunistic Infections?

A
  • Decrease of CD4 cells = decrease in cell-mediated immunity
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2
Q

At what CD4 Cell Count is the highest risk of starting to develop Opportunitic Infections?

A
  • < 500 cells/mm3 [expecially < 200]
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3
Q

What are some of the Opportunistic Infections that could occur at 200-500 CD4 cell count?

A
  • TB [Cough up blood, night sweats, weight loss]
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4
Q

What are some of the Opportunistic Infections that could occur at < 200 CD4 cell count?

A
  • Pneumocystis Jiroveci (PJP) [increased LDH, Hypoxia]
  • Crytosporidium [watery diarrhea]
  • Candida [Thrush, Oral Lesion]
  • Fungal Pneumonia
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5
Q

What are some of the Opportunistic Infections that could occur at < 100 CD4 cell count?

A
  • Toxoplasmosis [Ring Lesions on Brain]
  • Candidal, HSV or CMV esophagitis
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6
Q

What are some of the Opportunistic Infections that could occur at < 50 CD4 cell count?

A
  • CMV [Visual changes, esophagitis, entertitis…]
  • Cyptococcus [headache, altered mental, +india ink]
  • MAC [Night sweats, weight loss, diarrhea, malaise]
  • CNS Lymphoma
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7
Q

What is the difference between Primary & Secondary prohylaxis?

A
  • Primary: Agents to prevetn first episode based on CD4 levels
  • Secondary: Agents to prevent further recurrences of OIs
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8
Q

What does IRIS mean and what are some of the OIs that can induce IRIS?

A
  • IRIS: Immune Reconstitution Inflammatory Syndrome = high fevers, malaise, worse clinical outcomes of OI
  • Seen in: MAC, TB, PJP, Toxo, Hep B & C, CMV, Crypto, Histo, ZVZ

Typically begins wihtin 4 - 8 weeks of starting ARTs
Treat with NSAIDS or Cortiosteriods

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9
Q

What are the most common infections due to Candida Species?

A
  • Oropharyngeal Candidiasis [Thrush]
  • Esophegeal Candidiasis

mostly caused by C. Albicans

OPC = < 200 & EC is normall seen lower than that

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10
Q

What is the Clinical Manifestations and Management for Oropharyngeal Candidiasis?

“Thrush”

A
  • Painless, Creamy white, plaques on the cheek, roof of mouth or tounge
  • Topically: Nystatin or Clotrimazole [NOT for HIV]
  • Systemic: Fluconazole 100 mg PO QD for 7 - 14d –> Preferred (superior to topical)
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11
Q

What is the Clinical Manifestations and Management for Esophageal Candidiasis?

A
  • Fever, Retrosternal Burning, swallowing pain and difficulty
  • Systemic: Fluconazole 200 mg IV or PO QD for 14 - 21 days –> Topical NOT effective
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12
Q

What is the Clinical Manifestations and Management for Vulvovaginal Candidiasis?

A
  • Thick, adherent white vaginal discharge, itching, burning, redness
  • Treatment: Topical Azoles; Oral fluconazole; Itraconazole Solution [Severe = PO Fluconazole >7days] (C. Glabrata = Boric Acid Vaginal Suppository)
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13
Q

When should Prophylaxis be used for any Candidiasis OIs?

A
  • NOT recommended –> only superficial and Not life threatening
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14
Q

What is the Clinical Manifestations and Management for Cryptocccal Meningitis?

3 Phase Managmetn –> Induction, Consolidation, maintenance

A
  • Can have fever, malaise, headache, neck stiffness [subacute (chronic) meningitis]
  • Treatment: induction: L AMP B + 5-FC ~12w then consolidation: fluconazole 800 gm PO QD for ~8w then maintenacne: fluconazole 200 PO QD for 1y
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15
Q

What is some of the diagnosis for Cryptococcus Meningitis?

A
  • CSF analysis = normalish glucose, few WBCs, Elevated Cryptococcal antigen
  • Patients also have + Serum Cryptococcal Antigen Titer
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16
Q

What is the Primary Prophylaxis for Cryptococcal Meningitits?

A
  • NOT Rcommended
17
Q

What is the Secondary Prophylaxis for Cryptococcal Meningitis?

A
  • Chronic or Suppressive Therapy with PO Fluconazole for 1 year
  • Can D/C if Asymptomatic and CD4 > 100

35 - 65% patient with AIDS will relapse

18
Q

What are some important things to note about Pneumocystis Jirovecii Pneumonia (PJP)?

Pathogensis?

A
  • PJP is allover our bodies but the the skin help protect
  • Most of the cases (90%) develop in HIV patients with a CD4 count < 200 or 14%
19
Q

What is the Clinical Manifestations of Pneumocysits Jirovecii Pneumonia?

A
  • SOB, Fever, Non-productive cough, and chest discomfort that takes days to weeks to delevop
  • Exam: Tachycardiam Tachypenia, SOB

CAP has the same signs but its sudden onset

20
Q

What is the diagnosis of PJP?

A
  • Arterial Blood gas: Hypoxemia (pO2 < 70)
  • CXR: Diffuse, bilateral, symmetrical, “ground glass”
  • High 1,3 b-D-glucan [part of the cell wall]
21
Q

What is the treatment for PJP?

A
  • TMP-SMX 15-20mg/kg/day of TMP IV/PO q6-8h for 21 days
  • Adjuctive Corticosteriods for MOD-SERVERE [When PaO2 < 70; start prednisone 40mg BID x5d; 40 mg QD x5d; 20 mg QD x11d]

Pred should be started at the same time as Bactrim
Untreated = fatal

22
Q

What the is Primary Prophylaxis for PJP?

When to start? Drugs? D/C?

A
  • Helps prevent First episode fo PJP in ALL HIV patients [CD4 < 200; 14%]
  • Bactrim DS PO QD or SS PO QD
  • D/C when CD4 count is 100-200 for 3m

Bactrim DS good for Toxo [CD4 < 100]

23
Q

What is the Secondary Prophylaxis for PJP?

When to start? Drugs? D/C?

A
  • Given after completion of treatmetn for ALL
  • Bactrim DS PO QD or SS PO QD
  • D/C when CD4 count is > 200 for 3m

Bactrim DS good for Toxo [CD4 < 100]

24
Q

What are some of the alternactive prophylaxis for PJP

A
  • Bactrim DS three times weekly
  • Dapsone 100mg PO QD
  • Atovaquone 1500mg PO QD (with food)
  • Pentamidine 300mg/month

Dapsone NOT good for Toxo

25
Q

What are some important things to note about Toxoplasma Gondii Encephalitis?

A
  • Caused by Protozoa in raw or undercooked meats [lamb, beef, pork], Shellfish [oystersm clams, mussels], soil, cat poo
  • Happens because fo reactivation when CD4 is low
  • Occurs when CD4 is < 100
26
Q

What is the clinical manifestations of Toxo?

A
  • Headache, confusion, motor weakness, fever

Similar to Encephalitis

27
Q

What are some of the things that can help with the Diagnosis of Toxo?

A
  • Sermu Toxoplasma gondii IgG + [doesnt really mean you have it]
  • PCR of CSF
  • MRI of the brain because of the Ring Lesion of brain
  • Stereotatic CT for those that are not responding to empiric treatment
28
Q

What is the treatment for Toxo?

A
  • TMP-SMX 10mg/kg/day based on TMP component
  • Pyrimethamine (+leucovirin) + Sulfadiazine [NOT really used]
  • Adjunctive Corticosteriods [Dexamethasone]
29
Q

What is the primary prophylaxis for Toxo?

When to start? Drugs? D/C?

A
  • (+) IgG should get it to prevent Toxo when CD4 < 100
  • TMP/SMX DS PO QD
  • D/C when CD4 count > 200 for 3m

Alternatives: Bactrim SS PO QD or DS 3 times weekly, Dapsone 50mg + Phyrimethamine 75mg + Leucovorin, Dapsone 200mg + Pyrimethamine 75mg + Leucovorin 25mg, Atovaquone 1500mg +/- pryrithmathamine 25mg + Leucovorin 10mg

30
Q

What is the secondary prophylaxis for Toxo?

When to start? Drugs? D/C?

A
  • After completing treatment
  • Pyrimethamine 25 to 50mg PO QD + Sulfadiazine 2000 to 4000mg PO QD + Leucovorin 25 mg PO QD
  • D/C when CD4 count is > 200 for 6m

Alternatives: Clindamycin 600mg + Pyrimethamine, Bactim DS PO BID or QD, Atovaquone

31
Q

What are some of the ways for preventing the exposure to Toxo?

In those that are IgG +

A
  • DO NOT eat raw meets
  • Wash fruits and vegs
  • Wash hands after touching soil
  • If Pregnant; have non-pregnant person clean the litter box
32
Q

What are some important things to note about Mycobacterium Avium Complex [MAC]?

A
  • VERY common systemic, bacterial infection
  • Occurs in late HIV infection when CD4 is < 50
33
Q

What is the clinical presentation of MAC?

A
  • Gradual onset
  • Fever, Night Sweats, Weight Loss, Diarrhea, Abdominal pain, fatigue
  • Exams: Hepatosplenomegaly, Acid-Fast Bacilli blood culutre [MACS are this], Bone marrow, lymph nodes, stools that show MAC
34
Q

What is the treatment for MAC?

A
  • Clarithromycin or Azithromycin [1st line]
  • (+) Ethambutol [2nd line]
  • (+/-) Rifabutin [3rd line]
  • Have disseminated MAC = ART ASAP

2 or more antimycobacterial drugs

Drug Interactions with ARTs too

35
Q

What is the Primary Prophylaxis for MAC?

When to start? Drugs? D/C?

A
  • NOT recommended for who immediatly initiate ART
  • IS for those NOT on ART: Azithromycin 1200mg po weekly
  • D/C in those started on ART or CD4 > 100

Alternative: Clarithromycin 500mg PO BID, Azithromycin 600mg PO twice weekly

36
Q

What is the secondary prophylaxis for MAC?

A
  • Given to ALL patients with MAC after 1 year of treatment
  • Clarithormycin 500mg PO BID + Ethambutol 15mg/kg PO QD +/- Rifabutin 300mg PO QD
  • D/C when completed 12m of therapy, Asymptomatic with CD4 > 100 for > 6m

Alternatives: Azithromycin 500 to 600mg PO QD + Ethambutol 15mg/kg PO QD +/- Rifabutin 300mg PO QD

PHRM 865: Theraputics V (42 decks)

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